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Contents lists available at ScienceDirect

Child Abuse & Neglect

Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative夽 Laurel J. Kiser a , Carla Smith Stover b,c , Carryl P. Navalta d,∗ , Joyce Dorado e , Juliet M. Vogel f , Jaleel K. Abdul-Adil g , Soeun Kim h , Robert C. Lee i , Rebecca Vivrette j , Ernestine C. Briggs k a University of Maryland School of Medicine, Division of Psychiatric Services Research, Department of Psychiatry, 737 West Lombard Street, Fifth Floor, Baltimore, MD 21201, USA b University of South Florida, Mental Health Law and Policy Department, 13301 Bruce B. Downs Blvd., Tampa, FL 33612, USA c Yale University Child Study Center, 230 South Frontage Road, New Haven, CT 06520, USA d Boston University School of Medicine, Mental Health Counseling and Behavioral Medicine Program, 72 East Concord Street, Suite B-2903, Boston, MA 02118-2526, USA e University of California, San Francisco, Child and Adolescent Services, Department of Psychiatry, San Francisco General Hospital, Box 0852, SFGH CAS, San Francisco, CA 94110-0852, USA f North Shore Hospital/Zucker Hillside Hospital, Department of Psychiatry, 400 Community Drive, Manhasset, NY 11030, USA g University of Illinois at Chicago, Institute for Juvenile Research (MC 747), Department of Psychiatry, 1747 West Roosevelt Road, Room 155, Chicago, IL 60608-1264, USA h University of California, Los Angeles, Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA 90095-1772, USA i Duke University Medical Center, National Center for Child Traumatic Stress, 411 West Chapel Hill Street, Suite 200, Durham, NC 27701, USA j University of Maryland, Department of Psychiatry, 701 West Pratt Street, Baltimore, MD 21201, USA k Duke University School of Medicine, UCLA-Duke National Center for Child Traumatic Stress, 411 West Chapel Hill Street, Suite 200, Durham, NC 27701, USA

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Article history: Received 8 November 2013 Received in revised form 25 February 2014 Accepted 28 February 2014 Available online xxx

Keywords: Child abuse Child–perpetrator relationship Mental health outcomes Child traumatic stress

a b s t r a c t The present study was conducted to better understand the influence of the child–perpetrator relationship on responses to child sexual and physical trauma for a relatively large, ethnically diverse sample of children and youth presenting for clinical evaluation and treatment at child mental health centers across the United States. This referred sample includes 2,133 youth with sexual or physical trauma as their primary treatment focus. Analyses were conducted to ascertain whether outcomes were dependent on the perpetrator’s status as a caregiver vs. non-caregiver. Outcome measures included psychiatric symptom and behavior problem rating scales. For sexual trauma, victimization by a non-caregiver was associated with higher posttraumatic stress, internalizing and externalizing behavior problems, depression, and dissociation compared to youth victimized by a caregiver. For physical trauma, victimization by a non-caregiver was also associated with higher posttraumatic symptoms and internalizing behavior problems. The total number of trauma types experienced and age of physical or sexual trauma onset also predicted several outcomes for both groups, although in disparate ways. These findings are consistent with other recent studies demonstrating that perpetration of abuse by caregivers results in fewer symptoms and problems than abuse perpetrated by a non-caregiving relative. Thus, clinicians should not make a priori assumptions that children and adolescents

夽 This article was developed (in part) under grant numbers 3U79SM054284-10S, 5U79SM058147-04 (LJK), K23 DA023334 (CSS) and 5U79SM059297-03 (JKAA) from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. ∗ Corresponding author. http://dx.doi.org/10.1016/j.chiabu.2014.02.017 0145-2134/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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who are traumatized by a parent/caregiver would have more severe symptoms than youth who are traumatized by a non-caregiver. Further exploration of the role of the perpetrator and other trauma characteristics associated with the perpetrator role is needed to advance our understanding of these findings and their implications for clinical practice. © 2014 Elsevier Ltd. All rights reserved.

Exposure to traumatic events in childhood has been associated with a myriad of adverse consequences throughout the lifespan, including detriments to physical health, mental health, and quality of life (Holbrook et al., 2007); and a number of studies have demonstrated that poly-traumatization increases risk of maladaptive outcomes. Most notably, these findings have been elucidated in the Adverse Childhood Experiences (ACE) studies (Anda et al., 2006). The field of child traumatic stress has now moved beyond simply examining the frequency of traumatic experiences to investigating the mechanisms by which details of the traumatic experience affect outcomes. Important trauma details previously identified in the literature include type of trauma, age of exposure, duration, frequency, severity, and degree of threat (Bulik, Prescott, & Kendler, 2001; Keiley, Howe, Dodge, Bates, & Pettit, 2001; Manly, Kim, Rogosch, & Cicchetti, 2001). One trauma detail in particular that has received considerable attention, specifically in the area of child maltreatment, is the relationship of the perpetrator to the child survivor. The first generation of studies examining the closeness of survivor–perpetrator relationships initially focused on individuals who experienced sexual trauma during childhood. A review of several early studies of sexual trauma survivors demonstrated that a ‘close’ relationship with the perpetrator is associated with more serious, long-term effects (KendallTackett, Williams, & Finkelhor, 1993), although the authors noted variation in the definition of closeness across studies (e.g., counting fathers and step-fathers as equally close). These findings contributed, in part, to the theoretical basis for subsequent studies of betrayal trauma theory (BTT; Freyd, 1994, 1996), which posits that the impact of high betrayal traumas (i.e., physical, emotional, or sexual trauma perpetrated by an emotionally close, necessary individual in the child’s life, which might include a parent or a close relative) results in poorer outcomes over time in comparison to similar trauma perpetrated by a more emotionally distant individual or stranger. Although generally supporting the relationship between perpetrator closeness and adverse outcomes, two early reviews of child sexual abuse pointed out that many studies have failed to demonstrate an effect of perpetrator–child relationship on child symptoms (see reviews by Beitchman, Zucker, Hood, & DaCosta, 1991; Browne & Finkelhor, 1986). More recent studies have also failed to find that relationship closeness (Hébert, Collin-Vézina, Daigneault, Parent, & Tremblay, 2006) or familial relationship (Maikovich-Fong & Jaffee, 2010) predicts child mental health outcomes. In line with the points highlight by Kendall-Tackett et al. (1993), one criticism of investigations focusing on perpetrator–child relationships has been the operationalization of ‘closeness’ based solely on demographic variables, such as biological relationship (e.g., biological father, step-father) or marital status of the parents (Dubowitz, 2009; Yancey & Hansen, 2010), rather than the child’s emotional and physical dependency on the perpetrator. These investigations recommended that future studies define perpetrators according to the degree of the caregiving responsibility, emotional closeness, or dependency, rather than kinship category. Application of demographically based definitions of the child–perpetrator relationship diverge significantly from the recommendation of Kendall-Tackett et al. (1993) to focus on the degree of caregiving responsibility rather than kinship status. Studies that have followed the definitional strategy endorsed by Kendall-Tackett et al. (1993) have found varying results regarding the influence of the child–perpetrator relationship on mental health outcomes. For example, Leahy, Pretty, and Tenenbaum (2004) found that adults who reported sexual trauma by a perpetrator in a relationship of trust, guardianship, or authority had more severe posttraumatic and dissociative symptoms than adults who reported abuse by other perpetrators, although further qualitative analyses indicated that emotional manipulation of the child survivor, rather than the perpetrator relationship itself, may differentiate between survivors with clinical and non-clinical levels of symptoms. In contrast, Sadowski et al. (2003) found that girls who reported sexual trauma by a stranger were more likely to experience Major Depressive Disorder, Separation Anxiety Disorder, and impairment of general functioning compared to girls who reported sexual trauma by a ‘parent figure’. Such equivocal results highlight the need for theoretical models and definitional consistency to guide research toward a better understanding of the role of the child–perpetrator relationship (Lawyer, Ruggiero, Resnick, Kilpatrick, & Saunders, 2006). Recent BTT studies have expanded their scope to examine other forms of trauma in addition to sexual trauma, such as physical and emotional maltreatment. In fact, a number of studies have found that high betrayal traumas, which could potentially include sexual, physical, and/or emotional victimization, are significantly related to higher symptoms of anxiety, depression, dissociative tendencies, posttraumatic stress, suicidality, panic, anger, and physical health complaints compared to similar traumas perpetrated by a stranger or emotionally distant individual (DePrince, 2005; Edwards, Freyd, Dube, Anda, & Felitti, 2012; Freyd, Klest, & Allard, 2005; Goldsmith, Freyd, & DePrince, 2012; Martin, Cromer, DePrince, & Freyd, 2013; Tang & Freyd, 2012). Although the focus of these studies has been placed on adverse outcomes of traumatic experiences in childhood, the generalizability of these findings to treatment-seeking, trauma-exposed children and adolescents is somewhat problematic for two reasons. First, the majority of BTT studies have been conducted with community samples of adult survivors who retrospectively reported their child trauma histories. The trajectory of these participants’ responses to child trauma is thus widely unknown as they were not seeking treatment for trauma-related concerns and did not report on their functional impairment during childhood. Measures of betrayal trauma have also exclusively focused on emotional

Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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closeness with the perpetrator, rather than on dependency for caregiving needs (i.e., physical nurturance as well as emotional support). Additionally, BTT studies have recently expanded to capture multiple forms of child trauma; however, most of these studies have not explicitly examined differential effects among trauma types experienced. For example, significantly less attention has been placed on youth who have experienced physical trauma compared to sexual trauma. Relatively few studies have systematically investigated the child–perpetrator relationship in the context of physical trauma, although some evidence exists that youth who were physically maltreated by a family member are at greater risk of developing posttraumatic stress disorder (Boney-McCoy & Finkelhor, 1995). Two areas that have been studied in the context of physical trauma in childhood are suicidality and memory impairment. Suicidality has been associated with physical trauma perpetrated by family members, caregivers, and adults living in the home (see Mironova et al., 2011, for a review), and adult survivors of physical trauma demonstrate greater memory impairment related to the abuse than survivors who were maltreated by non-caregivers (Freyd, DePrince, & Zurbriggen, 2001). Aside from the aforementioned studies, a paucity of findings exists in the child physical trauma literature on the role of child–perpetrator relationships on mental health outcomes (Lawyer et al., 2006). In accordance with Kendall-Tackett et al.’s (1993) call to emphasize perpetrator caregiving responsibility, the primary aim of the present study was to investigate the extent to which the caregiving role of the perpetrator (i.e., caregiver vs. noncaregiver) is associated with mental health functioning among clinic-referred youth within the National Child Traumatic Stress Network. In contrast to BTT studies, clinic-referred child survivors were evaluated and specifically categorized as to whether they were maltreated by someone in a caregiving vs. a non-caregiving role. Due to high rates of polyvictimization in this sample (Briggs et al., 2013), we focused on youth for whom the primary focus of treatment was either sexual trauma or physical trauma. Our primary hypothesis was that trauma perpetrated by a caregiver is associated with greater psychological symptoms than trauma perpetrated by a non-caregiver. The overarching aim of the project was to fill an important gap in the field by aiding our understanding of the child–perpetrator relationship and its effects on exposure to child abuse that is based on a relatively large, diverse sample of children and adolescents presenting for clinical evaluation and treatment at child mental health centers across the United States.

Methods Participants Data for this study were obtained from the National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS). Data in the CDS were collected from 14,088 children and youth aged birth to 21 years who presented for clinical evaluation due to exposure to a traumatic event (e.g., physical abuse, sexual abuse, domestic violence, accident) at one of 56 NCTSN-funded centers across the United States from 2004 to 2010. NCTSN centers include community-based, hospital, and university organizations providing mental health services for youth (for further information about the CDS, see Briggs et al., 2013; for further information about the NCTSN, see Pynoos et al., 2008). De-identified and aggregated data from the CDS were used for the present analyses. Data were stored at the Duke Clinical Research Institute under the regulatory protection of the Duke University Health System Institutional Review Board. The sample examined in this study (n = 2,133; 15% of total cases in the CDS) included youth aged 6–18 years, who presented for a clinical evaluation for mental health concerns at an NCTSN center with sexual or physical trauma as their primary focus of treatment. The sample was limited to this age group as it aligns with the lower and upper age limits for the standardized measures that were administered. Sexual and physical traumas as the focus of treatment were further classified within the CDS according to whether the trauma was perpetrated by an individual in a caregiving role (i.e., labeled abuse in the CDS) or by an individual in a non-caregiving role (i.e., labeled assault in the CDS). Caregivers could include any individual in a caregiving role for the child, such as a biological parent, step-parent, or grandparent. Examples of non-caregivers would include a relative not caring for the child, neighbor, or a stranger. Within this sample, 949 (44.5%) of the youth had sexual trauma perpetrated by a caregiver as the specified focus of treatment; 552 (25.9%) had sexual trauma perpetrated by a non-caregiver; 534 (25%) had physical trauma perpetrated by a caregiver; and 98 (4.6%) had physical trauma perpetrated by a non-caregiver. Clinicians were provided with standard definitions for these trauma types and used all available information to endorse trauma details. All potential sources of information were used to complete the baseline evaluation, including intake initial interview(s) with the child and/or caregiver and medical record review. Information regarding traumatic experiences, perpetrator relationship, and other portions of the interview were provided by the child (when developmentally appropriate, 60.6%) as well as their non-offending parent (66.3%), foster parents (8.7%), and other collaterals (31.1%). Table 1 summarizes the demographic characteristics of the sample within the four categories. The majority of youth in the sample were female (67.7%); the mean age of this group at evaluation was 12.6 years. The sample was 14% Hispanic or Latino, 37% White non-Hispanic, and 25% Black non-Hispanic. The majority of the youth were living at home with their parents/caregiver (61.4%) rather than in foster care or residential settings, and the majority were under parent guardianship (71.6%) compared to state (14.7%) or kinship (8.8%) guardianship. Of those records that included an indication of insurance coverage, a large majority of youth were receiving care covered by public assistance (82.7%). Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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Table 1 Demographic characteristics of the sample by focus of treatment. Sexual trauma

Caregiver (N = 949) N (%) Age (M, SD) Sex Male Female Race White Black Hispanic Multiracial Other Residence Home w/ Parents Foster Care Other Insurance Private Public Both

Physical trauma

Non-caregiver (N = 552) N (%)

Caregiver (N = 534) N (%)

Total (N = 2133) N (%)

Non-caregiver (N = 98) N (%)

12.1 (3.1)

13.3 (3)

12.4 (3)

14.1 (2.9)

12.6 (3.1)

207 (21.8%) 742 (78.2%)

108 (19.6%) 444 (80.4%)

314 (58.8%) 220 (41.2%)

60 (61.2%) 38 (38.8%)

689 (32.3%) 1444 (67.7%)

338 (37.9%) 197 (22.1%) 150 (16.8%) 188 (21.1%) 19 (2.1%)

193 (37.1%) 125 (24%) 70 (13.5%) 114 (21.9%) 18 (3.5%)

185 (38.1%) 149 (30.7%) 52 (10.7%) 84 (17.3%) 15 (3.1%)

24 (26.7%) 23 (25.6%) 14 (15.6%) 24 (26.7%) 5 (5.6%)

740 (37.2%) 494 (24.9%) 286 (14.4%) 410 (20.6%) 57 (2.9%)

517 (63.3%) 113 (13.8%) 187 (22.9%)

392 (76.6%) 24 (4.7%) 96 (18.8%)

246 (49.8%) 104 (21.1%) 144 (29.1%)

70 (79.5%) 6 (6.8%) 12 (13.6%)

1225 (64.1%) 247 (12.9%) 439 (23%)

110 (14.9%) 613 (83.2%) 14 (1.9%)

89 (20.7%) 337 (78.4%) 4 (0.9%)

48 (11.4%) 365 (86.7%) 8 (1.9%)

13 (19.1%) 55 (80.9%) –

260 (15.7%) 1370 (82.7%) 26 (1.6%)

Table 2 describes the sample in terms of relevant trauma details and covariates used in modeling. Youth in this sample primarily experienced trauma by a single perpetrator type (i.e., parent, adult relative, unrelated adult, sibling, other youth, stranger, unknown) and their sexual or physical trauma was typically repeated rather than a single event. The average age of onset of their sexual or physical trauma was 7.4 years. Youth in the sample endorsed exposure to 3.8 different types of trauma on average. Measures Demographic variables included in this study were age, sex, and race/ethnicity. Race and ethnicity were categorized as follows: White (non-Hispanic), African American (non-Hispanic), Hispanic/Latino, Multiracial, and Other. Other variables of interest were extracted from the Trauma History Profile (THP) portion of the CDS. The THP, which serves as the in-depth trauma screener for the UCLA PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004) includes a thorough list of trauma exposures, including: (a) sexual maltreatment/abuse, (b) sexual assault/rape, (c) physical abuse/maltreatment, (d) physical assault, (e) emotional abuse/psychological maltreatment, (f) neglect, (g) domestic violence, (h) war/terrorism/political violence inside the U.S.; (i) war/terrorism/political violence outside of the U.S.; (j) illness/medical, (k) injury/accident, (l) natural disaster, (m) kidnapping, (n) traumatic loss/separation/bereavement, (o) forced displacement, (p) impaired caregiver, (q) extreme personal/interpersonal violence (not reported elsewhere), (r) community violence (not reported elsewhere), (s) school violence, and (t) other trauma (any other type of trauma not captured by this list). Clinicians determined and indicated whether a trauma did not occur, was suspected to have occurred, or was confirmed to have occurred Table 2 Salient trauma details by focus of treatment. Sexual trauma

Number of perpetrators Single Multiple Frequency of trauma exposure One-time event Repeated exposure

Age of onset # of trauma types experienced

Physical trauma

Caregiver (N = 949) N (%)

Noncaregiver (N = 552) N (%)

Caregiver (N = 534) N (%)

765 (90.6%) 79 (9.4%)

443 (91%) 44 (9%)

414 (86.3%) 66 (13.8%)

65 (84.4%) 12 (15.6%)

130 (17.2%) 625 (82.8%)

227 (48.8%) 238 (51.2%)

43 (9.4%) 413 (90.6%)

45 (52.3%) 41 (47.7%)

Noncaregiver (N = 98) N (%)

(M, SD)

(M, SD)

(M, SD)

(M, SD)

7.4 (3.5) 3.7 (2.5)

9.9 (3.8) 3.7 (2.4)

5.8 (4) 4.3 (2.4)

11.6 (3.4) 3.7 (2.2)

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through clinical information available to the clinician during the intake evaluation process (e.g., child interview, information from caregivers, Child Protective Service records). The THP was used to assess exposure to all trauma types, irrespective of the focus of treatment or reason for referral. For the current study, trauma endorsement was defined as confirmed exposure only. Standard, detailed definitions were provided to staff for all trauma types and were modeled after the National Child Abuse and Neglect Data System (NCANDS) Glossary (NCANDS, 2000). Staff also participated in mandatory trainings and ongoing quality assurance through the National Center for Child Traumatic Staff to ensure integrity of the data. For each trauma endorsed, clinicians provided additional information about the experience on the Trauma Details Form (e.g., age of onset of each trauma type, whether the trauma was a one-time event or a repeated exposure). Trauma details utilized for the current study were age of onset of physical or sexual trauma, single or multiple perpetrators, and frequency of exposure. Proxy variables for the severity of exposure (e.g., penetration during sexual abuse) were not available for analysis either due to lack of administration or substantial missing information on trauma details. Standardized measures included in the CDS are the UCLA PTSD Reaction Index for DSM-IV (UCLA PTSD-RI; Steinberg et al., 2004; Steinberg & Brymer, 2008), the Trauma Symptom Checklist for Children-Alternate (TSCC-A; Briere, 1996), and the Child Behavior Checklist for ages 6–18 (CBCL/6–18; Achenbach & Rescorla, 2001). These measures were administered by trained clinicians at each center. For the current study, data presented on the UCLA PTSD-RI represents children ages 7–18 and data on the TSCC-A represents children ages 8–18. The UCLA PTSD-RI measures exposure to and symptoms of trauma in 7–18 year-olds. Twenty-items directly asses DSM-IV criteria for Posttraumatic Stress Disorder (PTSD) symptoms while two additional items assess associated fear of recurrence and guilt. Frequency of occurrence of PTSD symptoms during the past month is rated on a 5-point scale (from 0 = none of the time to 4 = most of the time), with scores of 38 and above indicating likely PTSD. The UCLA PTSD-RI can be used as either a self-report or clinician-administered instrument. Reliability and validity are fairly robust (Steinberg et al., 2004, 2013). Internal consistency of UCLA PTSD-RI Total Score for the current sample was .99. The TSCC-A consists of 44 self-report items used to assess post-trauma symptoms in 8–16 year olds. The TSCC-A includes five clinical scales (anxiety, depression, anger, posttraumatic stress, and dissociation) and two validity scales (underresponding and hyper-responding). Items are rated on a Likert-type scale, with 0 indicating never and 3 indicating almost all the time. The clinical cut-off score for the TSCC-A is 65 with scores of 60–64 indicating borderline range of psychopathology. The measure has been standardized on a large sample of diverse youth and has strong psychometric characteristics (Briere, 1996; Briere & Lanktree, 1995; Diaz, 1994; Elliot & Briere, 1994; Evans, Briere, Boggiano, & Barrett, 1994; Singer, Anglin, Song, & Lunghofer, 1995). Cronbach alphas for TSCC-A subscales in the current sample were 0.82 for the anxiety subscale, 0.81 for the depression subscale, and 0.85 for the dissociation subscale. The CBCL 6–18 requires a caregiver to rate, on a three-point scale as 0 (not true), 1 (sometimes true), or 2 (often true), each of 113 problems as they are perceived to reflect the child’s behavior over the past six months. The instrument has 8–9 subscales that can be collapsed into broadband scales: Internalizing scale, Externalizing scale, and a Total scale score. Statistical data on reliability and validity have been well-established and are reported elsewhere (Achenbach & Rescorla, 2001). The clinical cut-off score for the CBCL on the broadband scales is a T-score greater than 63 with a score of 60–63 considered to be in the borderline range of psychopathology. Internal consistency of the scales of the CBCL for the current sample was above .89. Data Analysis Central goals of the analysis were to understand possible differences in psychological outcomes with regards to whether the perpetrator of a trauma was in a caregiving role. All modeling was done using SAS 9.2 statistical software with general mixed regression models that included random effects for the NCTSN center. This analytic strategy acknowledges that each center in the study represents a sub-sample of all centers and accounts for the variation among sites, thus extending the inferential results to patients from all such centers. The models also included fixed effects adjustments for youth age, gender, and race/ethnicity. Youth whose primary focus of mental health treatment was indicated as any type of physical trauma or any type of sexual trauma were included in the sample. Cases were stratified according to whether they indicated physical or sexual trauma as the primary focus of treatment. Predictors included in the regression analysis were: age of onset of physical or sexual trauma (Step 1), multiple (1) vs. single (0) perpetrators (Step 2), multiple (1) vs. single (0) exposures to physical or sexual trauma (Step 3), caregiver (1) vs. non-caregiver (0) perpetrated the trauma as the primary focus of treatment (Step 4), and total number of traumas experienced (Step 5). Dichotomous predictors were dummy coded prior to entry. Cases who erroneously included a stranger as a perpetrator of caregiver physical or sexual trauma were excluded (n = 6 for sexual trauma; n = 0 for physical trauma). Continuous outcome variables included scores on the UCLA PTSD-RI Total Severity scale; CBCL Internalizing and Externalizing scales (T-scores); and Anxiety, Depression, and Dissociation scales of the TSCC-A. Results Mixed regression models for sexual trauma by a caregiver vs. non-caregiver revealed that sexual trauma perpetrated by a non-caregiver resulted in significantly higher scores on the UCLA PTSD-RI Total Severity score, CBCL Internalizing and Externalizing T-scores, and the TSCC-A Depression and Dissociation scales at the time of treatment intake (see Table 3). Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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Table 3 Results for mixed models predicting specific mental health outcomes. Effect ␤ (SE)

Modeled mental health outcome UCLA PTSD-RI

Focus of treatment Sexual trauma (n = 1501) Age of onset Number of perpetrator types (multiple vs. single) Frequency of exposure (multiple vs. single) Perpetrator role (caregiver vs. non-caregiver) Number of trauma types Physical trauma (n = 632) Age of onset Number of perpetrator types (multiple vs. single) Frequency of exposure (multiple vs. single) Perpetrator role (caregiver vs. non-caregiver) Number of trauma types

0.3 (0.1)* 1.8 (1.7)

CBCL externalizing

−0.3 (0.1)* 1.7 (1.4)

−0.5 (1.2)

−0.3 (0.9)

−2.2 (1.1)*

−2.8 (0.9)**

1.2 (0.2)**

−0.3 (0.2)

0.9 (0.2)**

−0.4 (0.2)*

CBCL internalizing

TSCC-A depression

TSCC-A dissociation

0.01 (0.15) −0.2 (1.75)

0.2 (0.1) 1.1 (1.6)

0 (0.1) 0.7 (0.8)

1.2 (0.9)

−0.2 (1.2)

1.3 (1.1)

0.1 (0.5)

−1.9 (0.9)*

−1.6 (1.1)

−2.6 (1.0)*

−1.3 (0.5)*

−0.1 (0.1) 1.7 (1.4)

0.8 (0.2)**

−0.2 (0.2) −0.3 (2)

2.1 (2.2)

1.4 (1.9)

3.1 (2.3)

1.2 (2)

1.3 (2.1)

−5.2 (2.4)*

−2.6 (2.1)

−5.3 (2.3)*

0.7 (0.3)*

0.3 (0.3)

0.6 (0.3)

TSCC-A anxiety

0.7 (0.2)**

0.7 (0.2)**

0.3 (0.1)**

−0.4 (0.2)*

−0.2 (0.2)

0 (0.1)

0.4 (2.2)

−1.2 (2.1)

−0.4 (1)

0.2 (2.3)

2.3 (2.2)

0.8 (1)

−1.7 (2.4)

−1.9 (2.3)

−0.9 (1.1)

0.3 (0.3)

0.3 (0.3)

0.2 (0.1)

Note. Models also adjusted for race/ethnicity and sex. Note. Reference group listed first in contrasts (i.e., 1 vs. 0). * p < .05. ** p < .01.

Regarding other predictors in the model, number of trauma types experienced by the child was significantly associated with all outcome variables assessed. Age of onset of sexual trauma also was significantly associated with UCLA PTSD-RI Total Severity scores and CBCL Externalizing T-scores with older age of onset of sexual trauma associated with greater posttraumatic symptoms and younger age of onset associated with increased externalizing symptoms. For physical trauma, youth who were victimized by perpetrators in a non-caregiving role endorsed greater posttraumatic symptoms on the UCLA PTSD-RI and had higher scores on the CBCL Internalizing scale (see Table 3). Younger age of onset of physical trauma resulted in significantly higher CBCL Externalizing and TSCC-A Anxiety scores. Greater numbers of trauma types experienced was associated with higher UCLA PTSD-RI Total Severity scores. As the number of trauma types experienced was highly significant for most of the modeled outcomes, interaction terms were tested to see if the relationships between perpetrator role, number of trauma types, and the respective outcomes were more complex. In each case, this term did not contribute significantly to the model, implying the relationships between the number of trauma types and each outcome was relatively unchanged with regard to perpetrator role. Models were also examined without adjustment for the number of experienced trauma types. In each, both the direction of the effect of a caregiver perpetrator and the magnitude of that effect was left relatively unchanged. Discussion Prior research and clinical work have underscored the importance of examining perpetrator–child relationships in evaluating child abuse outcomes. Considerable evidence in research with adult non-clinical samples has indicated worse adult outcomes when the individual, as a child sexual trauma victim, had been dependent on and/or trusted the perpetrator (e.g., Goldsmith et al., 2012). Early research with child samples (e.g., Kendall-Tackett et al., 1993) also seemed to support this finding, but contained issues of precision in defining of relationships. More recent studies have presented more mixed findings (e.g., Sadowski et al., 2003). Thus, although clinical findings with children have been mixed, the primary hypothesis of the current study was that sexual trauma perpetrated by a caregiver would be associated with greater symptoms than sexual trauma perpetrated by someone not serving in a caregiving role. We also examined whether a similar pattern would extend to childhood physical trauma. The current analyses, however, failed to support these hypotheses. Instead, the findings indicate that sexual trauma Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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perpetrated by a non-caregiver was associated with significantly higher symptom levels (on both child self-report and caregiver-report measures) than sexual trauma perpetrated by a caregiver. Similarly, physical trauma perpetrated by a noncaregiver was associated with higher levels of symptoms in child survivors than physical trauma perpetrated by a caregiver based on both child and caregiver report, although the finding was less robust than for sexual trauma. These associations remained significant even when controlling for other potentially important variables such as age of onset and number of other traumas experienced. Because the current study’s participants were children involved in clinical services, this study differs from most studies showing an association between caregiving perpetrators and higher symptom levels in survivors of CSA. Indeed, the majority of studies that showed worse outcomes for individuals abused by people in positions of trust (family members, caregivers, closer relationships) have been based on adult non-clinical samples (e.g., Goldsmith et al., 2012; Leahy et al., 2004) with a similar pattern observed for a national non-clinical survey of adolescents (Lawyer et al., 2006). Kendall-Tackett et al.’s (1993) review reported that seven of nine child studies that examined child–perpetrator relationships found more symptoms for ‘closer’ relationships. The clinical status of the children (i.e., whether or not children were referred for or engaged in mental health services), however, was not reported for this subset of studies, and the authors noted that ‘closeness’ was not uniformly defined in the studies reviewed. The relatively few studies of perpetrator effects among clinical samples have not demonstrated an association between closeness of child–perpetrator relationship and psychiatric symptoms. In fact, one study of clinic-referred girls found that non-caregiver perpetration predicted higher rates of Major Depression, Separation Anxiety Disorder, and poor general functioning (Sadowski et al., 2003). Two other studies of clinical (Hébert et al., 2006) and Child Protective Service (Maikovich-Fong & Jaffee, 2010) samples of youth have failed to demonstrate a relationship between perpetrator status and psychiatric symptoms. Several explanations for our findings are plausible. These explanations revolve around possible factors in the nature of the trauma, possible developmental issues in the onset of symptoms, protective factors associated with help-seeking, or impact of relationships on reporting (rather than experiencing) of symptoms. Each of these areas is discussed in detail below.

Possible Impact of the Relationships on the Nature of the Abuse The relationship between a child and a caregiving perpetrator is more likely to be multifaceted (compared to when the perpetrator is not a caregiver), involving both positive, nurturing characteristics as well as abusive ones. The positive aspects of the caregiving relationship may be protective and contribute to some level of resilience for the child survivor, leading on balance to fewer adverse symptoms, at least initially. Related to the complexity of the relationship, caregiving perpetrators may ascribe different meanings to their abusive behavior. That is, perpetrating caregivers may tell the child that the abusive acts are done out of love and caring (e.g., Lang & Frenzel, 1988) or may explain physical abuse as discipline that was administered for the good of the child, which could result in different symptom outcomes. Children whose perpetrators were non-caregivers may be more likely to perceive the traumatic acts committed against them as wrong and this perception could account for them having a higher level of symptoms than their abused counterparts. For example, Kolko, Brown, and Berliner (2002) found that a diagnosis of PTSD (vs. no PTSD diagnosis) was associated with child victims’ greater endorsement of perceived victimization (i.e., their perception that they were treated in an inappropriate and unfair way). In addition, sexual trauma perpetrated by a caregiver may have different characteristics than when perpetrated by a non-caregiver or close family member (e.g., level of violence, level of invasiveness). For example, comparable to our findings, Lucenko, Gold, and Cott (2000) found higher levels of post-traumatic symptoms among adult survivors of CSA whose perpetrators were not in a caregiving role (vs. in a caregiving role). They hypothesized that perpetrators who were not in caregiving roles may have been more violent or otherwise extreme in their sexually traumatizing acts causing greater symptoms. Indeed, they found that females sexually traumatized by a caregiver reported less accompanying physical abuse than those sexually traumatized by a non-caregiver. Similarly, Fischer and McDonald (1998) found that sexual abuse by a non-family member was likely to include more use of force as part of the sexual acts. The use of force by a perpetrator of sexual abuse has been found to be associated with greater symptoms (Kendall-Tackett et al., 1993).

Possible Developmental Factors and Delayed Onset of Impact of Some Aspects of Caregiver Abuse A developmental factor that could potentially act in concert with the complexity of the relationships with a caregiver (vs. a non-caregiver) perpetrator is that child survivors may need greater cognitive development and/or social experience to fully appreciate the inappropriateness of the caregiver’s behavior. Perhaps it is not until middle adolescence to adulthood that one might understand just how wrong it is for a caregiver – someone who has so much power, responsibility, and influence – to take advantage of her/his power in the relationship. Indeed, recent evidence indicates that initial episodes of depression can emerge years after onset of exposure to sexual abuse, with a surge in onset of depression between 12 and 15 years and beyond – at least when assessed retrospectively in young adults (Teicher, Samson, Polcari, & Andersen, 2009). A developmentally informed framework, including more prospective longitudinal research following survivors after Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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disclosure (as also recommended by Yancey & Hansen, 2010), is imperative to better understand the possibility of later emergence of symptoms not initially seen during childhood assessment. Possible Protective Aspects of Help Seeking A third factor is that the issue of betrayal of trust may be at least partially mitigated for a child clinical sample compared to adult community samples specifically as a result of help-seeking. Studies of community samples of adults have found that those who were victimized as children often show long delays in reporting abuse or may never report the experiences; furthermore, at least for physical and emotional abuse, evidence exists that those abused as children by people in positions of trust are less likely to report the abuse to others or do so after longer delays (Foynes, Freyd, & DePrince, 2009). Perhaps a protective factor is present for children in clinical samples in that someone was concerned about their distress and brought them for assessment and/or treatment and that identification of the abuse was made either prior to referral or as part of the evaluation process, which then led to the abuse being taken seriously. Possible Underreporting of Impact of Caregiver Abuse Finally, rather than experiencing lower levels of adverse symptoms, child survivors and their participating caregivers in our study may have selectively under-reported symptoms when a caregiving perpetrator existed due to the respondents’ relationship with the perpetrator. Children (who filled out the TSCC-A and UCLA PTSD-RI) and their caregivers (who filled out the CBCL) may be more protective of an individual on whom the children have relied for care, and with whom the caregivers may have had an intimate relationship. They may have reported fewer negative symptoms, whether the children were experiencing them or not. This hypothesis is consistent with a study examining factors associated with recantation of substantiated sexual abuse cases, which found that children were more likely to recant if the perpetrator was a “parent figure” (Malloy, Lyon, & Quas, 2007). This possible under-reporting may particularly be an issue at the onset of treatment before a trusting relationship has been formed with a therapist. Clinical Implications These findings, based on data from a sample of children and adolescents referred for services, have particular relevance for clinical work. They suggest that clinicians must pay close attention to a child survivor’s understanding of the meaning of a sexual or physical trauma and attend to the possibility of complex feelings, both negative and positive, toward caregiving perpetrators. Similarly, clinical interventions should take into consideration the multifaceted nature of a caregiver–child relationship – positive aspects of which may be lost when a caregiving perpetrator is removed from the child’s life. The nature of such loss may well need to be one of the foci of treatment. In addition, if childhood help-seeking and trauma-specific treatment, together with living with adults who support the treatment, were shown to significantly mitigate the “betrayal trauma” issues involved in childhood trauma by a caregiver, such evidence would have major clinical implications for the field. This amelioration would provide support for initiatives promoting screening and assessment. In addition, treatment developers could incorporate psychoeducation regarding the long-term effects and therapeutic strategies designed to help children make sense of the relational dynamics involved in trauma. Moreover, multiple clinical evaluations across developmental epochs are warranted for children who are initially assessed to exhibit none-to-low levels of mental health symptoms post-abuse who would then not receive treatment. Two major reasons for such multi-time point evaluations are (a) possible initial under-reporting/under-estimating of problems as discussed above and (b) possible significant delays in symptom emergence. When assessments are conducted in this manner, the evaluations would allow assessors to ‘catch’ the presence of symptoms sooner, which could then lead to earlier (and hopefully more effective) treatment. Such an approach could potentially mitigate the sometimes disabling symptoms that are seen in adult survivors of childhood abuse who do not seek treatment until many years later. Similarly, follow-up over time of children who do receive treatment is important to ascertain the long-term impact of treatment and extent to which interventions provide protection from later symptom development. Limitations of Current Study Because the CDS was designed as a quality improvement initiative, the NCTSN sample is neither probability-based nor representative of the general population of children and adolescents exposed to trauma (Briggs et al., 2013). Rather, this sample is a large national one of children and adolescents referred to clinics that provide trauma-focused mental health services. Although cognizant of these limitations, we saw the CDS as a valuable resource as, to our knowledge, no national databases have been utilized to explore the child–perpetrator relationship. The validity of our data is also bolstered by the fact that we obtained a number of secondary findings congruent with the existing literature, such as higher levels of symptoms across all outcome variables being correlated with higher number of trauma types experienced (Anda et al., 2006; Kaltman, Krupnick, Stockton, Hooper, & Green, 2005). In addition, a major strength of the current study is that the findings were drawn from an unusually rich and diverse dataset representing clinical populations. However, this strength is also a Please cite this article in press as: Kiser, L. J., et al. Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It’s (not) all relative. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.017

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limitation in that sexual and physical trauma are often not disclosed or discovered until long after the trauma has occurred (e.g., Smith et al., 2000). Thus, the fact that our sample is comprised of children who were referred for evaluation around these traumas makes our findings non-generalizable to populations not referred for clinical services. Whether the perpetrator was the primary caregiver and the perpetrator’s gender were not reported in this sample, which limits interpretation of the findings related to these factors. In addition, while we recognized the importance of controlling for variables that could influence the symptom picture of child survivors, some of the characteristics of the trauma that could be important in this regard were difficult to garner with sufficient accuracy or specificity from this dataset (e.g., severity of abuse; level of seriousness of injury resulting from sexual trauma; exact duration of abuse; and non-offending parent’s response to disclosure of sexual trauma; see Yancey & Hansen, 2010). Implications for Further Research Although the study findings were counter to our original hypothesis, they are consistent with several other studies (Lucenko et al., 2000; Sadowski et al., 2003), suggesting the need for future research to examine the nature of the caregiving role in relation to symptoms following physical and sexual trauma. For example, an understanding of whether or not child outcomes would differ if the perpetrator was a primary caregiver or even a sole caregiver would be illuminating, as could examining other details of the caregiver relationship (e.g., length of caregiving relationship; quality of the caregiver–child relationship; father vs. mother; and biological parent vs. step-parent vs. foster parent). Additionally, follow-up studies would be useful to determine whether any increase in report of symptoms occurs once a therapeutic alliance between the therapist and the child has been established and when children have a clearer understanding of what happened as being both inappropriate and not the child’s responsibility. Moreover, longitudinal studies of youngsters who initially screen as asymptomatic can help to determine if symptoms emerge only at later developmental stages, such as adolescence. The possibility of help-seeking by non-offending caregivers as a protective factor can be evaluated further in two ways: (a) examining the impact of delay between the abuse disclosure and onset of treatment in a sample of youth presenting for treatment following caregiver abuse; and (b) studying the impact of childhood trauma-specific treatment on betrayal trauma within adult community samples. Also, given that the level of family support post-abuse is a critical factor that influences child outcomes, the extent to which a family maintains a relationship with the perpetrator warrants study. Finally, given the unavailability of potentially important trauma details in the current dataset, in future studies investigating the influence of the perpetrator–child relationship, more detailed data collected in regard to level of severity of traumatic experiences, including violence, injury, and invasiveness of sexually or physically traumatic acts, would help to clarify the meaning of the current findings. Summary Previous studies have shown inconsistencies about the effects of the child–perpetrator relationship on mental health outcomes of children and youth who have been abused. On the one hand, some investigators found that outcomes are worse for those youth who have a ‘close’ relationship with the abuser. In contrast, others demonstrated the opposite or that the degree of closeness between the child and perpetrator has no differential effect. The present study was designed to further examine the potential impact of the caregiving relationship on outcomes using a large sample of treatmentreferred youth who presented with sexual or physical trauma as the focus of concern. Based on this specific referred sample, findings indicate that trauma perpetrated by a caregiver did not lead to higher levels of symptoms for child survivors of sexual or physical abuse in this sample. Several possible explanations for these findings have been delineated including (a) the child–perpetrator relationship and its impact on the nature of the abuse, (b) developmental factors in the emergence of impact of the breach of trust in the child–caregiver relationship, (c) impact of help-seeking as a mitigating factor, and (d) underreporting of symptoms when a close relationship with the perpetrator is present. Lastly, clinical and research implications of the findings are presented. 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